New Customer Enquiry Form for The 1:1 Diet with Katherine Fenny

New Customer Enquiry Form

The 1:1 Diet with Katherine Fenny
A little bit about you

- this is so I can get to know a little bit about you and how I can help you reach your goals
Name*

First NameLast Name
Gender*
Pronouns
Email*
example@example.com
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

DayMonthYear
Date
Have you done The 1:1 Diet (Cambridge Diet) before?*
Lifestyle and Medical

These answers help me to recommend the best plan for your weight loss journey
Height*
Please enter your approximate Weight*
Please enter your approximate Measurements - Bust/Chest, Waist at Tummy Button, Hips
Your Occupation
Please indicate your level of Activity
Do you have and medical conditions?*

YesNo
If Yes, please provide details
Do you take any medication?*

YesNo
If Yes, please provide details
Are you using GLP-1 medication?*

YesNo
Delcaration for clients who are using GLP-1 medication:

1. The information I provided is correct, and I have been advised to consult my GP or GLP-1 practitioner before using these products for nutritional support.

2. I confirm that I have purchased my GLP-1 products via an authorised prescriber.

3. I understand that I will be using the products as a meal replacement (MRP) for nutritional support and am not following a specific Step plan.

4. I understand the requirement to provide my weight for the purpose of calculating BMI.

5. I acknowledge that my Consultant can provide guidance on the selected products and thier nutritional value but will not offer support on my weight loss journey.

6. I am aware that it is my responsibility to fully understand the contraindications and possible side effects of GLP-1.

7. If I wish to follow a Step with The 1:1 Diets, I understand that I must discontinue GLP-1 for at least two weeks before starting the program.

8. I accept responsibility for ensuring I consume enough fibre while following GLP-1.
Please confirm by ticking the box to agree with the declaration.

I agree with the above statement, regarding the use of GLP-1
Do you have any Allergies/Intolerances or Dietary requirements?*

YesNo
If Yes, please provide details
Have you had any general accidents or any surgery in the last 3 months?*

YesNo
Women only: have you given birth in the last 3 months?*

YesNo
Women only: are you currently breastfeeding?*

YesNo
Use this space to note anything else you think I should know or if you have any questions ahead of our chat ...
Space expands so type away!
NOTE: The 1:1 Diet by Cambridge Weight Plan is NOT appropriate for those who are alcoholic, substance misusers, underweight, pregnant, breastfeeding, or who have given birth in the last 3 months, and those younger than 14 years.
How did you hear about me?
Please confirm the following and sign the declaration:

1. The information given is correct and I have been advised to consult my GP before starting any weight loss programme.

2. I understand the importance of following the selected Step according to directions given by my Consultant and additional literature supplied by CWP.

3. If my health status/medication changes while using any CWP Step, I agree to notify my Consultant.

4. I understand that there is a legitimate interest in CWP and my Consultant holding the data on the Personal Record Form in conjunction with the use of the Programme. I understand it may be necessary for you to provide data to medical professionals and vice versa in relation to me starting the Programme and that this is a viral interest which forms the legitimate basis for processing.

5. I am aware that it is my responsibility as a client to have regular medial reviews with my GP to assess any medical adjustments.

6. I have been supplied with the relevant CWP booklet and CWP privacy notice by my consultant and I have read and understood these prior to completing this form.
Please confirm and tick the box to agree with the declaration.*

I agree with the above statement
I consent to my Consultant contacting me at any point regarding my weight loss journey, promotions and any business opportunities. If I wish to withdraw my consent at any stage I can do so by sending an email to my Consultant.
Signature*

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I declare that the information given is correct. I consent to my Consultant contacting me at any point regarding my weight loss journey.
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New Customer Enquiry Form

A little bit about you

Lifestyle and Medical